oral health for the older adult phase 3 5-30 · 2018-06-13 · 2 upon completion of this module,...

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Interprofessional Geriatrics Training Program

HRSA GERIATRIC WORKFORCE ENHANCEMENT FUNDED PROGRAM Grant #U1QHP2870 EngageIL.com

Oral Health for the Older Adult

Author: Robert Rada, DDS, MBA

Editors: Valerie Gruss, PhD, APN, NP-BC

Memoona Hasnain, MD, MHPE, PhD

Expert Interviewee: Robert Rada, DDS, MBA

Acknowledgements

Oral Health in Older Adults

• Over 50% of adults over 65 are edentulous

• Over 25% of 65- to 74-year-olds have severe periodontal disease

• Individuals living in long-term care (LTC) facilities are likely to receive

inadequate dental care

• Oral pharyngeal cancers are primarily diagnosed in the elderly

• Most elderly individuals take prescription and OTC medications which

cause xerostomia [not in narration]

(U.S. Department of Health & Human Services, 2000)

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Upon completion of this module, learners will be able to:

1. Describe the unique oral health needs of the older adult

2. Identify the oral health needs of the severely medically compromised older adult

3. Discuss the utilization of oral hygiene maintenance therapies for

older adults with dentures

4. Describe assessment and management of common oral health problems

including xerostomia, stomatitis, dysphagia, aspiration pneumonia,

candidiasis, and oral cancers

Learning Objectives

Oral Health Strategic Framework, 2014-2017

• Total health and wellness are inextricably linked to oral health

• Oral disease has an impact on physical, psychological, social, and economic

health and well-being, often resulting in pain, diminished function, and

reduced quality of life

(U.S. Department of Health & Human Services, n.d.)

Interview with Expert: Robert Rada, DDS, MBA

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Listen to Our Expert Discuss:

• Impact of oral health on overall health

• Oral health contributes to overall quality of life

• Poor oral health can impact a patient’s ability to:

• Smile

• Chew

• Interact with others

• Communicate

Expert Interviewee: Robert Rada, DDS, MBAImpact of Oral Health on Overall Health

• Older adults are more likely than any other age groups to have medical

conditions, such as diabetes and cardiovascular disease, that worsen their

oral health, and vice versa

Other Medical Conditions and Oral Health


• Oral health has implications for diabetes

• Poor gum disease and abscesses in the mouth can have a negative impact on

glycemic control and diabetic health

• Many areas of association with poor oral health and systemic illnesses

Expert Interviewee: Robert Rada, DDS, MBAImpact of Oral Health on Overall Health

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• Approximately 1 in 5 people in all age groups has untreated dental caries

• Not all can find adequate coverage for care, as Medicare does not provide oral

health services

• The percentage of adults (age 65 and older) who reported they did not obtain

dental care because they could not afford it doubled from 3.5% in 2001 to

7.0% in 2011

Other Medical Conditions and Oral Health



• Affording oral health care

• Medicare does not cover oral health unless the individual is in the hospital

and it is required for a procedure

• Dental care is among the top five costs that elderly individuals incur

Expert Interviewee: Robert Rada, DDS, MBAAffording Oral Health Care


• Other options for affording care

• Many plan in their retirement savings for dental care

• Medicaid is an option for others, but in some states it does not cover

adult care at all

• Illinois Medicaid has limited coverage for dental care with low

reimbursements


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• Other options for affording care (continued)

• Federally Qualified Health Centers, public health clinics, and dental

schools are options for receiving care at a reduced cost

• Incurred medical expenses are also an option in a nursing home setting

• Nursing home fees can pay for dental care and be reimbursed by

Medicare



• Due to to the high costs associated with dental care, many elderly people go

without dental care

• Many patients have had good dental care because they had dental insurance

throughout their lifetime, but when they reach retirement age, many are

unable to receive quality care


Goals of the Oral Health Strategic Framework, 2014-2017

1. Integrate oral health and primary health care

2. Prevent disease and promote oral health

3. Increase access to oral health care and eliminate disparities

4. Increase the dissemination of oral health information and improve

health literacy

5. Advance oral health in public policy and research


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As We Age, So Do Our Teeth and Oral Soft Tissues

Photos Not in Film

Patients of Dr. Rada granted permission to take photos for educational use

This is Not Just “Getting Older”

Oral CancerDenture Sore

Photos Not in Film


Assessment Question 1

Which of the following is incorrect?

a) Over 25% of 65- to 74-year-olds have severe periodontal disease

b) Over 50% of adults over 65 are edentulous

c) Oral pharyngeal cancers are rarely diagnosed in the elderly

d) Individuals living in long-term care facilities are likely to receive


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Assessment Question 1: Answer

Which of the following is incorrect?

a) Over 25% of 65- to 74-year-olds have severe periodontal disease

b) Over 50% of adults over 65 are edentulous

c) Oral pharyngeal cancers are rarely diagnosed in the elderly

(Correct Answer)

d) Individuals living in long-term care facilities are likely to receive


Xerostomia (Dry Mouth)

Xerostomia (Dry Mouth) Outcomes

• Constant thirst

• Dysphagia

• Altered speech

• Difficulty wearing dentures

• Oropharyngeal infections

• Difficulty moving food around

the mouth

• Mucous accumulation

• Food retention

• Plaque accumulation

• Changes in oral flora

• Mucosal tissue changes

• Taste alterations

• Dental caries

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What Does Dry Mouth Look Like?

SevereToothDecay

Photos Not in Film


Listen to Our Expert Discuss:• How dry mouth impacts the older adult

• When the mouth is dry, there is less saliva• Saliva has a number of protective factors that are valuable to the

oral cavity• When a patient has a dry mouth, tissues do not feel comfortable and are

not lubricated well, causing food and the tongue to move poorly around the mouth

• When the mouth becomes dry, teeth can rub against the cheeks, mucosa, or lips, causing redness and pain

Expert Interviewee: Robert Rada, DDS, MBADry Mouth and Older Adults


• How dry mouth impacts the older adult (continued)

• Discomfort in chewing their food

• Dry mouth can limit an individual’s ability to taste food

• Saliva has protective factors that protect against cavities

• With less saliva, the potential for cavities increases


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• How dry mouth impacts the older adult (continued)

• Older adults frequently have some recession on their teeth, meaning

the roots are showing

• Roots are prone to decay, and the root can be destroyed in a matter of

months without the enzymes and saliva that will protect against cavities


How the Provider Can Counsel the Patient

• As a clinician, dry mouth is a common issue that needs to be addressed in all

older adults, but there are management techniques to combat the side

effects of xerostomia

• Advise patients to:

• Avoid sugary snacks between meals

• Consider using oral lubricants

• Ask their dentist about prescription fluoride toothpastes


• Best way to combat xerostomia

• Variety of artificial saliva products and substitutes, such as glycerin

Expert Interviewee: Robert Rada, DDS, MBACombatting Xerostomia

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Denture Care

Denture Adhesives

• As over 50% of adults over 65 are edentulous, dentures and denture

adhesives are a widely-used solution

• Sales for denture adhesives alone are in excess of $200 million

• However, there are issues that accompany the use of dentures, such as

denture sores

Denture Adhesives

Two Categories of Denture Adhesive• Insoluble:

• Pads and wafers• Useful for very atrophic jaw bones

• Soluble:• Creams, pastes, and powders• More difficult to clean, easy to apply• Apply in modest amounts• Often swell by 50%-150% to cover the needed surface area to create a

comfortable wear

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• Common problems older adults experience related to dentures

• Dentures present challenges because, when a patient has dentures, the

patient does not have the same chewing power that they would with even

a few teeth in the mouth

• An upper denture often fits well, while lower dentures are frequently

mobile and present more challenges

• Dental implants are now available, which allow the denture to be anchored

Expert Interviewee: Robert Rada, DDS, MBADentures


• Common problems older adults experience related to dentures (continued)

• The looseness common in lower dentures can be remedied in many patients

• Some patients fear dental implants because of the surgery involved, but it is

often a fairly non-invasive procedure

• Even patients with complex medical histories can receive dental implants to

remedy their dentures




• For patients with dentures that have some mobility, denture adhesives are

a good option

• Denture adhesives are used to cushion the denture and to provide

retention for the individual

• However, the denture should be examined by a dentist to see if it is

properly fitting


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• If the denture is properly fitting and the adhesive is used as an adjunct,

that is an appropriate solution

• However, if the denture is ill-fitting and the adhesives are being used to

hold a poor-fitting denture in place, then the person could develop

problems with sores, infections under the denture, and difficulties in

keeping the denture clean


Denture Stomatitis: Causes

• Denture stomatitis, or denture sore mouth,

is also a common problem

• Can be caused by:

• Fungal infection (C. albicans)

• Poor denture hygiene, denture fit, nutrition

• Immunosuppression

• Wearing dentures continuously day and night

(U.S. Department of Health & Human Services, 2000)

Photo Not in FilmPatients of Dr. Rada granted permission

to take photos for educational use

Denture Stomatitis: Treatment

• Daily denture cleaning with a modified brush

• Wear dentures only during the day

• Rinse mouth with nystatin

• Soak dentures in nystatin mixed with water

• Address denture fit (relining as needed) and systemic issues

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Modified Brushes

Photos Not in Film

Photos courtesy of Dr. Rada


• How a caregiver can help with an older adult’s denture stomatitis

• Many older adults do not take their dentures out at night, or rarely remove

them at all, which can lead to a buildup of plaque

• Important for the caregiver to take the denture out, brush the denture

under simple soap and water, place the denture in denture cleaners and

rinse before placing back in the mouth

Expert Interviewee: Robert Rada, DDS, MBADenture Stomatitis


• How a caregiver can help with an older adult’s denture stomatitis (continued)

• It is also important for the caregiver to go into the person’s mouth with a

simple wet gauze or moist washcloth to wipe the tissues

• This is done to ensure that everything is smooth, that the person will not

get a buildup of food, and to reduce the potential for discomfort

Expert Interviewee: Robert Rada, DDS, MBADenture Stomatitis

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Management: Mucositis and Stomatitis

Chemo- and Radiation Therapy:

• Lidocaine viscous 2%

• Lidocaine spray 10%

• Diphenhydramine hydrochloride 5%

and loperamide in equal parts*

(dyclonine 0.5% may be added to

increase potency*)

• Dyclonine hydrochloride* 0.5% or 1%

• Magic mouthwash

• Sucralfate suspension 10 mL 4 times a

day, swished and swallowed or

expectorated

• Benzydamine* 15 mL 3-4 times/day,

rinsed and expectorated

• Morphine 2%

• Reduction of potential localized factors

• *Off-label use, not FDA approved for

stomatitis


• How chemotherapy affects the mouth

• Several problems are associated with chemotherapy because it is a

generalized therapy that affects all the tissues in the body

• Some types of chemotherapy can cause canker sores in the mouth

• Not all types of chemotherapy cause problems in the mouth, but many do

Expert Interviewee: Robert Rada, DDS, MBAChemotherapy and the Mouth


• What products are recommended for these issues

• Some products are available to help manage the sores caused by

chemotherapy

• The physician can prescribe a rinse, often called a magic mouthwash,

which can include magnesium hydroxide and diphenhydramine

• The magic mouthwash works as a general pain reliever and reduces

inflammation

Expert Interviewee: Robert Rada, DDS, MBAChemotherapy and the Mouth

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• How radiation therapy affects the mouth

• Radiation therapy only presents oral cavity challenges if it is head and

neck radiation

• Radiation therapy damages the salivary glands to the point where they

no longer produce saliva, which explains why radiation therapy causes

dry mouth

• This makes a patient highly susceptible to dental caries and dental decay

Expert Interviewee: Robert Rada, DDS, MBARadiation Therapy and the Mouth


• How radiation therapy affects the mouth (continued)

• Patients undergoing head and neck radiation often receive fluoride

trays for daily at-home use

• This allows the patient to continuously keep the teeth mineralized and

reduce the potential for cavities

Expert Interviewee: Robert Rada, DDS, MBARadiation Therapy and the Mouth


Stomatitis can be caused by poor denture hygiene, denture fit,

and nutrition. Patients wear dentures continuously throughout

the day and night.

a) Both statements are true

b) Both statements are false

c) The first statement is true; the second statement is false

d) The first statement is false; the second statement is true

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Stomatitis can be caused by poor denture hygiene, denture fit,

and nutrition. Patients wear dentures continuously throughout

the day and night.

a) Both statements are true

b) Both statements are false

c) The first statement is true; the second statement is false

(Correct Answer)

d) The first statement is false; the second statement is true

Oral Care for Patients with Dementia

Clinical Tips When Treating Dementia Patients

• Brush teeth from behind the patient with the patient seated in front of a

mirror, if possible

• Approach slowly, and be patient

• Reduce external noise

• Keep sessions as short as possible

• Ask caregiver to remain in the operatory (exam room)

• Consider using a mouth moisturizer

• If the patient becomes agitated, the session is over; try again later

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Clinical Tips for Patients with Disabilities

• For elderly patients or patients with disabilities, use chlorhexidine (CHX) spray,

which is easy to apply and chemically controls plaque

• Applying 0.2% CHX spray once daily is effective in reducing plaque

accumulation and gingival inflammation in institutionalized elderly patients

(Clavero et al., 2003)

Dysphagia

Dysphagia: Symptoms and Treatment

• Delayed swallowing, drooling, dysphonia, or coughing within one minute of

swallowing

• Adjust the consistency of food when necessary by:

• Thickening liquids (add gels, purees, etc.)

• Thinning foods and liquids (add water, juice, etc.)

• Help the patient maintain an upright position, as near 90 degrees as possible,

whenever eating or drinking

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Dysphagia: Educate Your Patients

• Take small bites and eat slowly

• Avoid talking while eating

• If one side of the mouth is weak, place food into the stronger side of the mouth

• At the end of the meal, check the inside of the cheek for any food that may

have been pocketed


You have an appointment with a patient who has dementia; to

make this appointment productive and comfortable for the

patient, you should do all of the following EXCEPT:

a) Reduce external noise

b) Ask the caregiver to remain in the exam room

c) Make the session longer than usual

d) Approach him/her slowly and be patient

e) Brush teeth from behind the patient with the patient seated in front

of a mirror, if possible


You have an appointment with a patient who has dementia; to

make this appointment productive and comfortable for the

patient, you should do all of the following EXCEPT:

a) Reduce external noise

b) Ask the caregiver to remain in the exam room

c) Make the session longer than usual (Correct Answer)

d) Approach him/her slowly and be patient

e) Brush teeth from behind the patient with the patient seated in front

of a mirror, if possible

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Which of the following statements is true with regard to managing patients with dysphagia?

a) Put the patient in a supine position and tell her/him to take small bites and eat slowly

b) Put the patient in an upright position (as near 90 degrees as possible) and tell her/him to take small bites and eat slowly

c) If one side of the mouth is weak, ask the patient to place food in the weaker side of the mouth to build resistance

d) All of the above


Which of the following statements is true with regard to managing patients with dysphagia?

a) Put the patient in a supine position and tell her/him to take small bites and eat slowly

b) Put the patient in an upright position (as near 90 degrees as possible) and tell her/him to take small bites and eat slowly (Correct Answer)

c) If one side of the mouth is weak, ask the patient to place food in the weaker side of the mouth to build resistance

d) All of the above

Aspiration Pneumonia

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• Approximately 1 in 10 cases of death from pneumonia in elderly long-term

care residents may be prevented by improving oral hygiene

• Oral biofilm, the plaque that forms on your teeth and causes tooth decay and

periodontal disease, can become colonized by respiratory pathogens and

serve as a reservoir for lung infection

• Good oral hygiene results in significantly fewer interventions for pneumonia

(Scannapieco, 2015)


• Pneumonia is the most common cause of death from nosocomial infection in

the elderly (Yoneyama et al., 2002)

• Aspiration pneumonia in nursing home residents occurs 10 times more

frequently than in elderly community dwellers (Quagliarello et al., 2005)


• Oral bacteria from dental plaque are carried to the lower respiratory tract

in saliva (Abe et al., 2008)

• Bacteria carried in saliva have been linked to pathogens involved in pneumonia (Abe et al., 2008)

• These bacteria are also linked to other systemic diseases

• One study suggests that 70% of patients with a history of pneumonia aspirated

during their sleep (Kukuchi et al., 1994)

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Aspiration pneumonia occurs from oral bacteria from dental plaque

being carried to the lower respiratory tract in saliva. Good oral

hygiene results in significantly fewer interventions for pneumonia.

a) True

b) False


Aspiration pneumonia occurs from oral bacteria from dental plaque

being carried to the lower respiratory tract in saliva. Good oral

hygiene results in significantly fewer interventions for pneumonia.

a) True (Correct Answer)

b) False

Candidiasis

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Management: Candidiasis

• Soak dentures in bleach solutions

• Use a nystatin suspension intervention

• Nystatin suspension can be:

• Used topically

• Swished and swallowed 3 to 5 times a day

• Frozen in a sugarless fruit juice

• Used in a vaginal suppository

Topical

Nystatin suspension,

200,000-500,000 IU,

swished and swallowed 3-5

times a day

Nystatin suspension frozen

(200,000-500,000 IU) in

sugarless fruit juice

Management: Candidiasis

• Clotrimazole is another treatment for candidiasis, and can be used as a

cream applied to dentures 3 to 4 times a day for seven days

Oral Cancer

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• Oral cancer is the eighth most common malignancy in the world, and the

incidence rate of oral cancer increases with age

• Oral squamous cell carcinoma accounts for 90% of all oral cancers

• Early carcinomas often go undetected because pain usually is not a factor

until the lesion is large

• 65% of oral cancers are not diagnosed until advanced stages

• The most common locations are the tongue and floor of the mouth

Oral Cancers.

(Haumschild et al., 2012)

• Leukoplakia, the most common premalignant lesion, is characterized as a

white patch that cannot be removed by scraping

• Erythroplakia, or red lesions, should be viewed with a high degree of suspicion

• Erythroleukoplakia, having both a red and white component, is more likely to

undergo malignant change

• Any lesion lasting more than two weeks should be suspicious for oral cancer

Oral Cancers.


• Early diagnosis is the most important consideration for improving patient

survival

• Oral cancer screenings are often omitted during physical assessments,

although older adults visit their primary care provider 5-7 times more often

than their dentist (Haumschild et al., 2012)

• More older adults consult their medical provider about oral lesions than

their dental professionals, as Medicare does not cover dental visits(Haumschild et al., 2012)

Oral Cancer Screenings.

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• The American Cancer Society recommends that primary care providers

examine patients at risk for oral cancer as part of a routine checkup because

this would give providers the opportunity to detect oral cancer at an early stage

• This is important because the 5-year survival rate is 83% for patients

diagnosed with localized lesions, compared to a 63% survival rate for all

stages combined


(American Cancer Society, 2016)

• Oral cancer screening includes:

• Comprehensive head, neck, and oral examinations, which include direct

extraoral observation, palpation, and intraoral measurements of

ulcerations, lumps, swellings, or growths

• These screenings are easy to perform, take 5 minutes to complete, and

can be done bedside or chairside (Haumschild et al., 2012)



Which statement regarding oral cancers is true?

a) The incidence rate of oral cancer decreases with age

b) The most common locations are the tongue and floor of the mouth

c) Early carcinomas are detected from the pain associated with the lesion

d) Erythroplakia is the most common premalignant lesion

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Which statement regarding oral cancers is true?

a) The incidence rate of oral cancer decreases with age

b) The most common locations are the tongue and floor of the

mouth (Correct Answer)

c) Early carcinomas are detected from the pain associated with the lesion

d) Erythroplakia is the most common premalignant lesion

• Screen for oral cancer, beginning with history and the extraoral examination

by palpating the head and neck

• Mention abnormalities to the patient to solicit further information

• Inspect the intraoral area for raised lesions and red or white patches

• Localize abnormalities by inspection and palpating of the lips, mucosa, palate,

tonsillar area, floor of the mouth, and tongue

• Evaluation, measurement, description, documentation, and referral when

indicated

SMILE.



• Neglected populations

• Dentists are especially good at treating patients who can come to their office

• Dentistry is lacking in the ability to go to the patient

• Access is a considerable challenge for people who are homebound or

cannot get to the dentist

• It is important for caregivers and providers to have an idea of the older

adult’s oral health because so often that area is not examined by any

provider but a dentist

Expert Interviewee: Robert Rada, DDS, MBANeglected Populations

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• Neglected populations (continued)

• Some corporations go into nursing homes, but their services are very limited

• The oral health of nursing home populations is very neglected

• Very important for other health providers to pay attention to the general

oral health care of their homebound older adult patients and to possess

some understanding of the mouth

Expert Interviewee: Robert Rada, DDS, MBANeglected Populations

References

Abe S, Ishihara K, Adachi M, & Okuda K. (2008). Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr, 47(2), 267-275. doi:10.1016/j.archger.2007.08.005American Cancer Society. (2016). Oral Cancer. Retrieved from https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/oral-cancer-fact-sheet.pdf. Accessed March 7, 2017Clavero J, Baca P, Junco P, González MP (2003). Effects of 0.2% chlorhexidine spray applied once or twice daily on plaque accumulation and gingival inflammation in a geriatric population. J Clin Periodontol, 30(9), 773-777.Haumschild MS, Haumschild RJ, & Holloway PL. (2012). The importance of oral cancer screenings by nurse practitioners. The Journal for Nurse Practitioners, 8(2), 117-122. doi:http://dx.doi.org/10.1016/j.nurpra.2011.09.020Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, & Sasaki H. (1994). High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med, 150(1), 251-253. doi:10.1164/ajrccm.150.1.8025758Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, & Tinetti M. (2005). Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis, 40(1), 1-6. doi:10.1086/426023U.S. Department of Health and Human Services. (2000). Oral health in America: A report of the Surgeon General. Retrieved from http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/[email protected]. Accessed July 14, 2016U.S. Department of Health and Human Services. (n.d.). Oral Health Strategic Framework 2014–2017. Retrieved from http://www.hrsa.gov/publichealth/clinical/oralhealth/oralhealthframework.pdf. Accessed July 26, 2016Scannapieco F. (2015). The oral microbiome and the risk of lung infection. Dimensions of Dental Hygiene, 13(4), 59-64.Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, Ihara S, Yanagisawa S, Ariumi S, Morita T, Mizuno Y, Ohsawa T, Akagawa Y, Hashimoto K, & Sasaki H. (2002). Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc, 50(3), 430-433.